What is the treatment for uterine fibroids?
Most uterine fibroids are harmless, do not cause symptoms, and go away with menopause. When treatment is necessary, treatment goals include relieving symptoms of pelvic pain or pressure and preventing anemia by correcting abnormal menstrual blood loss. For asymptomatic patients, no treatment is required. For patients with symptoms, medical options, including suppression of estrogen to stop the bleeding, are suboptimal and limited. Preoperative gonadotropinreleasing
hormone (GnRH) agonist therapy helps manage anemia before surgery. Menorrhagia or menometrorrhagia should be managed before surgery is considered.
Exogenous progestins can partially suppress estrogen stimulation of uterine fibroid growth. Medroxyprogesterone acetate 5 to 10 mg/day po or megestrol acetate 10 to 20 mg/day po given 10 to 14 days each menstrual cycle can limit heavy bleeding after one or two cycles. Alternatively, oral therapy may be given continuously (every day of the month); it may result in less overall bleeding but often causes irregular bleeding or spotting, which the patient accepts better if she is informed before therapy. Depot medroxyprogesterone acetate 150 mg IM q 3 mo controls bleeding similarly to continuous oral therapy and provides contraception. Before IM administration, oral progestins should be tried in case the patient cannot tolerate the adverse effects (eg, weight gain, depression, irregular bleeding).
Danazol, an androgenic agonist, can suppress fibroid growth but has a high rate of adverse effects (eg, weight gain, acne, hirsutism, edema, hair loss, deepening of the voice, flushing, sweating, vaginal dryness) and is therefore less acceptable to the patient.
GnRH agonists given by IM injection, subdermal pellet, or nasal spray are most helpful when given preoperatively to reduce fibroid and uterine volume. In general, these drugs should not be used for continued therapy because rebound growth to pretreatment size within 6 mo is common, often increasing bleeding and pain. Long-term GnRH therapy is also associated with rapid bone loss and is therefore not approved. In general, women < 35 yr old recoup bone mass after GnRH therapy is discontinued, but women >= 35 yr old cannot. Giving estrogen concurrently is being studied to determine whether its long-term use can prevent the bone loss.
Surgical options are myomectomy and hysterectomy; both involve major surgery. Surgery is usually reserved for women with a rapidly enlarging pelvic mass, recurrent uterine bleeding unresponsive to medical therapy, persistent or intolerable pain or pressure, or urinary or bowel complaints. Myomectomy may help women with recurrent abortions or infertility who want to conceive when no other cause of infertility can be found. Indications for hysterectomy are the same as those for myomectomy, but hysterectomy is performed only if the woman does not want to conceive. Multiple myomectomy can be much more difficult than hysterectomy. When the fibroids are removed, little or no normal myometrium may be left, making restoration of a normal uterus impossible. Patient choice is important, but it must be based on full information about the anticipated difficulties and sequelae of myomectomy vs. hysterectomy.
Another technique gaining popularity is uterine artery embolization (UAE), or uterine fibroid embolization (UFE). This procedure, which has been used to treat fibroids since 1995, is performed by a radiologist who uses advanced X-rays or other imaging techniques to find the exact location of your fibroid and the blood vessels around it. Once she finds your fibroid, she blocks the blood vessel that feeds it. Without blood, the fibroid eventually "starves," shrinks, and disappears. This procedure is less invasive than a myomectomy or hysterectomy (there's no incision, just a needle prick in your thigh or groin). It usually requires a one-night hospital stay, and most women resume their normal activities within a week or two, compared to four to six weeks for a surgical recovery. |
